Summary Here, CD40L expression and cytokine production have been analysed in peripheral blood cells from orthotopic liver transplantation (OLT) recipients treated with ribavirin for recurrent chronic hepatitis C. The study included 18 OLT recipients treated with ribavirin, eight control OLT recipients and 10 healthy controls. FACS analysis showed that baseline expression of CD40L was not different between ribavirin-treated patients and controls. In contrast, after stimulation with both HCV core antigen and phorbol myristate acetate (PMA) plus ionomycin (IO), the expression of CD40L on CD4 lymphocytes was significantly higher in the ribavirin group compared with controls. In the ribavirin group, the increased expression of CD40L significantly correlated with reduction of HCV RNA levels with respect to pretreatment values. Finally, ribavirin treatment was not associated with modification of PMA-IO-induced cytokine production by T lymphocytes and interleukin (IL)-1β and tumour necrosis-α (TNF)-α production by CD40L-stimulated monocytes. In conclusion, these data indicate that ribavirin upmodulates CD40L expression on CD4 T cells, a property which may account in part for its ability to enhance the antiviral activity of interferon-α in the treatment of chronic HCV infection.
ABSTRACT Background Postsurgical atrophic scars tend to respond poorly to treatments, especially non‐energy‐based ones. Hydrophilic PN HPT (Polynucleotides High Purification Technology) injected intradermally is a non‐energy‐based option with an immediate volume‐enhancing effect that indirectly improves the fibroblast synthesis of collagen and extracellular matrix. The PN HPT ingredient has the further benefit of a dermal “priming” effect that enhances the efficacy of other scar treatments. Objectives Verify retrospectively, with advanced techniques, the efficacy of PN HPT monotherapy as postsurgical scar treatment. Methods Retrospective data collection in 18‐ to 65‐year‐old women with moderate‐to‐severe atrophic scars after mammary surgery undergoing a five‐session intradermal treatment course with 0.75% PN HPT gel formulation in single‐use syringes starting 6 months after surgery. Primary retrospective efficacy parameter: changes in scar morphology and symptom severity after three and 6 months (modified Vancouver Scar Scale, mVSS). Secondary efficacy parameters: roughness score 6 months after baseline (Antera 3D CS tridimensional skin analysis system) and Global Aesthetic Improvement Scale (GAIS, Investigator and Patient subscales) after three and 6 months. Results Total mean mVSS highly significantly improved from 11.2 ± 1.92 at baseline to 7.0 ± 1.68 and 6.9 ± 1.55 after three and 6 months, respectively; the mean Antera 3D CS roughness score improved from 13.5 ± 4.14 to 10.0 ± 3.49 after 6 months. After three and 6 months, the GAIS subscores for investigators and cohort subjects were identical (3.0 ± 0.81 and 3.0 ± 0.72, respectively). The photographic documentation supported the previous results. Conclusions In monotherapy, the intradermal PN HPT ingredient seems to quickly and safely relieve the burden of postsurgical atrophic scars. However, the lack of a formal parallel control group is a severe limitation. The objective quantitative measurements confirmed the long‐lasting benefits.
Sir: “Bride burning” is a social phenomenon in countries such as India, Pakistan, and Bangladesh affecting thousands of young women every year.1,2 The ideal situation for these patients would be treatment in specialized facilities within the first month after injury. However, those few who survive are often referred 6 months to 2 years later and have, at this time, horrible disfigurements and functional limitations that keep them away from a correct reinsertion into society. In these cases, the challenge for plastic surgeons is to give them back the possibility of a dignified life.3 A 21-year-old Pakistani dancer who presented to us is a classic case of bride burning. Her husband, a local prince, repudiated the woman because of jealousy and burnt her in January of 1999 by throwing sulfuric acid on her face, neck, trunk, and arms. The resulting disfigurement and retractions destroyed her normal aesthetic appearance and completely impaired her neck movements (Fig. 1). From November of 1999 to September of 2005, we performed 14 reconstructive procedures to correct the anatomical and functional defects.Fig. 1.: Preoperative view of the patient in September of 1999.Different techniques were used in the face to correct complex scars situated in almost all regions. We used skin grafts, skin expanders, and Z and V-Y flaps to (1) expand the amount of skin available, (2) reconstruct it in zones where it was completely replaced by scars, and (3) interrupt the tension effect of retractions that limited movement. The inner canthus was managed with an inner canthoplasty (“dancing men” technique), the nasolabial area was managed with a Z flap to achieve an elongation in the direction of the natural groove, and the area between the nostrils and columella was managed with a V-Y flap. The reconstruction of the ear, a real challenge in plastic surgery, is usually performed with either of two techniques: autologous cartilage transplant or the use of implants. The latter has the advantages of stability, easy execution, low operative risks, minimal complication rate, better aesthetic result, and minor number of operations required; the disadvantages include continuous strict implant hygiene, sensibility loss, and possible patient refusal. We preferred implant reconstruction because of the experience gained in our institutions using this technique. Three screws were inserted in the mastoid region, behind the external acoustic meatus, sufficient to hold the auricular implant in place. Neck and arm contractures did not pose particular problems and were dealt with using Z-plasty techniques, insertion of expanders, and skin grafting. Postoperative physical rehabilitation was essential in preventing the formation of new contractures. Tissue damage caused by acids is similar to that resulting from thermal injuries but often requires a greater number of operations to yield acceptable aesthetic and functional results.3 Different parameters (e.g., scar type, extension, anatomical side, patient age, and gender) influence indications and surgical planning. In these complex cases of contracture and disfigurement, plastic surgeons must perfectly manage all available techniques of reconstruction and perform multiple operations over a period of years to provide an acceptable and dignified social life to the affected patient (Fig. 2).Fig. 2.: Final aesthetic appearance in October of 2005 after reconstructive operations.Antonino Araco, M.D. Gianpiero Gravante, M.D. Francesco Araco, M.D. Department of Surgery Pietro Gentile, M.D. Valerio Cervelli, M.D. Department of Plastic Surgery University of Tor Vergata Rome, Italy
The transversus abdominis plane (TAP) block is a technique of locoregional anesthesia that blocks the sensorial afferent nerves localized between the transversus abdominis muscle and the internal oblique muscle. We describe results obtained with a case control study between patients undergoing abdominoplasty with the TAP block compared with a similar group of patients not receiving the block.Medical notes were reviewed, and patients were classified according to the presence of TAP. Outcomes evaluated were the requirements of morphine in the first postoperative hour and the number of co-codamol tablets administered afterward.Seventy-five patients were screened. No intra- or postoperative complications were recorded. TAP+ patients required significantly less analgesia during the first 12 postoperative hours (P < 0.001). The patients with increased body mass index and large flap resected were more likely to fail the anesthetic block and required postoperative analgesia.In aesthetic abdominal surgery, the TAP block is safe, is performed without ultrasound guidance, and markedly reduces the requirement of postoperative opioid analgesia. Future studies will now confirm these results and evaluate the consequences in terms of postoperative nausea, vomiting, and overall satisfaction of patients.
Sir: Abdominoplasty is a procedure that manifests postoperative seromas in 5 to 22 percent of cases.1,2 Different risk factors have been investigated. Although age and body mass index have been associated with their occurrence,3 progressive tension sutures gave contrasting results, and the use of drains or concomitant liposuction was not related to seroma occurrence.4 In this retrospective analysis, we tried to correlate the risk of seromas with the amount of flap resected and of fat aspirated with liposuction. We also analyzed the influence of associated liposuction, progressive tension sutures, fibrin tissue adhesives (Tissucol), patient smoking status, and two techniques for flap raising (diathermocoagulation versus cold knife). Data were retrospectively collected from the personal archive of two surgeons (A.A. and V.C.) working at the Dolan Park Hospital, in Bromsgrove, United Kingdom, and at the Plastic Surgery Department of the University "Tor Vergata," in Rome, Italy. We excluded from the analysis morbidly obese and postbariatric patients who had undergone panniculectomy following massive weight loss. A total of 494 patients who underwent full abdominoplasty were analyzed (A.A.: September of 2004 to December of 2007; V.C.: January of 2001 to December of 2007). Descriptive statistics and clinical characteristics are summarized in Table 1.Table 1: Descriptive Statistics and Clinical CharacteristicsWe recorded 23 seromas (4.7 percent) and 34 hematomas (6.9 percent). Wound infections were present in 60 patients (12.1 percent). They occurred after a mean period of 8 ± 3 days. The most common organism isolated was Staphylococcus epidermidis. No cases of deep vein thrombosis or pulmonary embolism were observed. The chi-square and Mann-Whitney tests confirmed that groups (seromas versus nonseromas) were homogeneous for all variables analyzed, except for the amount of flap resected during the abdominoplasty (Table 1). The analysis of smoking status in both groups produced no significant differences, nor did the amount of flap aspirated with liposuction, the use of tissue adhesives, or the use of diathermocoagulation versus the cold knife approach. The comparison between groups produced a prognostic cut-off value for the amount of flap removed (Figs. 1 and 2). This value (700 g) was determined with receiver operating characteristic curves to find the greatest areas of sensitivity and specificity (area = 0.665). According to this cut-off, the relative risk for the incidence of postoperative seromas in patients who removed more than 700 g of fat was 3.8 compared with the others [(15/167)/(8/327)] (chi-square test; p < 0.001).Fig. 1.: Scatter plot with cut-off line for the amount of flap resected of patients who experienced seromas (red circles) versus those who did not (blue circles).Fig. 2.: Area of receiver operating characteristic (ROC) curves refers to cut-off of tissue removed. Diagonal segments are produced by ties.Results of our study suggest that the amount of fat removed during surgery could be an important factor for the occurrence of postoperative seromas, increasing their risk of occurrence almost four times when the quantity removed exceeded 700 g. We previously demonstrated that the quantity of fat removed influences the risk of pulmonary embolism when it exceeds 1500 g,5 and our personal observations also suggest a relationship with the occurrence of postoperative surgical-site infections. No other factor was associated with the occurrence of seromas, especially concomitant liposuction or the use of progressive tension sutures. However, although based on a large series, our analysis is retrospective in nature and the results obtained need to be confirmed in future prospective trials. A. Araco Dolan Park Hospital Bromsgrove, United Kingdom G. Gravante Department of Surgery Whipps Cross University Hospital London, United Kingdom F. Araco Dolan Park Hospital Bromsgrove, United Kingdom R. Sorge Department of Human Physiology Laboratory of Biometry University Tor Vergata Rome, Italy V. Cervelli Department of Plastic Surgery University Tor Vergata Rome, Italy
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